Chemotherapy-induced Nasopharyngeal Stenosis Treated with Bilateral Facial Artery Musculomucosal Flaps.

We report the first case of a 50-year-old woman who developed nasopharyngeal stenosis (NPS) after chemotherapy for malignant lymphoma. The chemotherapy was effective, but NPS developed following treatment. The tumors of the pharynx and soft palate became necrotic and turned into scar tissue, which caused NPS, especially in the caudal part of the soft palate. The patient developed nasal obstruction and obstructive sleep apnea due to the stenosis. The patient underwent 2 surgeries to resolve the NPS: the first was a simple incision of the stenosis, and the second was Z-plasty and mucous membrane transplantation from the posterior pharyngeal wall. However, the NPS recurred soon after these 2 surgeries. We used bilateral inferior-based facial artery musculomucosal (FAMM) flaps as a solution for recurrent NPS, and it was effective in preventing further stenosis. The blood supply to the flaps was stable, and the size of the flaps was enough to compensate for the area of tissue deficit. The use of bilateral FAMM flaps allowed both sides of the NPS to be corrected, and the flaps provided sufficient retracting strength to keep expanding the nasopharyngeal space by pulling from both sides. After the operation, nasal obstruction was decreased, and the sleep quality of the patient improved significantly. The velopharyngeal function was maintained, and there was no symptom of nasopharyngeal insufficiency. Our results suggest that the bilateral FAMM flap is a suitable method to rescue intractable cases of NPS.

Clinical Application of the Internal Mammary Artery Perforator Adipofascial Flap.

BACKGROUND: Skin ulcers on the anterior chest wall are caused mainly by radiation therapy for breast cancer and anterior mediastinitis after thoracotomy, and they are often refractory. Some muscle flaps are commonly used for anterior chest wall reconstruction, but muscle flaps accompany high invasion. We used the internal mammary artery perforator (IMAP) adipofascial flap and IMAP skin flap for the anterior chest wall reconstruction. METHODS: We examined the IMAPs using a handheld Doppler device and contrast-enhanced computerized tomography preoperatively. Each flap was designed based on the location of the IMAP and the size of the flap was dependent on the coverage required by the size and location of the skin ulcer. The location of the IMAPs functioned as the pivot point of the flap and the flap was flipped or swung on the defect. RESULTS: We used IMAP adipofascial flap for 2 cases and IMAP skin flap for 1 case. In those 3 cases, we could elevate the flap with no complications even after the internal mammary artery had been harvested. There was no recurrence of the skin ulcer or wound infection after the operation. CONCLUSIONS: In this study, we reported 3 cases of skin ulcer on the anterior chest wall reconstructed with the IMAP adipofascial and skin flap. To our knowledge, this is the first report of the use of the IMAP flap as an adipofascial flap. The IMAP adipofascial flap accompanies less invasion than muscle flaps and the surgical procedure is relatively easy. The IMAP adopofascial flap is considered as one of the effective means for anterior chest wall reconstruction.

Tasimelteon for treating non-24-h sleep-wake rhythm disorder.

INTRODUCTION: Non-24-h sleep-wake rhythm disorder (non-24) is observed in approximately half of totally blind individuals, a condition caused by their circadian pacemaker in the suprachiasmatic nucleus not being entrained to 24 h due to a lack of light perceptions. These subjects have a progressively delayed circadian cycle each day, non-24 periodically inducing nighttime insomnia and daytime sleepiness. Tasimelteon is a dual melatonin receptor agonist with high affinity for the melatonin 2 receptor, and it entrains endogenous melatonin rhythms and sleep-wake cycles in individuals with non-24. Areas covered: Herein, the authors review the treatment of non-24 with tasimelteon. The authors further compare tasimelteon with other melatonin receptor agonists. Expert opinion: The treatment strategies for non-24 aim to resynchronize the free-running rhythm with the 24 h light-dark cycle. Tasimelteon entrains circadian rhythms and improves the sleep-wake functions of individuals with non-24. Furthermore, the RESET study demonstrated that 20% of patients that discontinued tasimelteon maintained circadian entrainment whereas 90% of those who continued it maintained circadian entrainment. Long-term administration of tasimelteon is safe and well tolerated, and it is the only pharmacological therapy approved by the US Food and Drug Administration and the European Medicines Agency for non-24.

Late-onset congenital lateral dermal sinus tract.

Cases of laterally located, congenital dermal sinus tracts are extremely rare, with only six having been reported to date. We describe a case of a 14-year-old girl who developed symptoms of this type of sinus tract at an age that was considerably older than is usually reported. At the age of 12 years, the patient exhibited a purulent discharge from a pit on the right buttock. MRI indicated the presence of two tracts running from the right buttock skin to a cystic lesion that had formed on the right ala of the sacral spine. The lesion was surgically resected and successfully reconstructed using a partial iliocostalis lumborum muscle flap, without any functional morbidity. From our experience, such flaps appear to be appropriate treatment choices for lateral congenital dermal sinus tracts that develop late and result in large defects.